What is wrong with the NHS

The NHS is being reorganized again - or is it. In the wake of the Liberal Democrats defeat at the polls they are stiffening up their opposition to Andrew Lansley's Health Bill in the hope that they will be seen by the electorate as still having some backbone.

The Health Bill was an attempt to make the NHS more accountable to its users by giving control of the budgets to consortia of local family doctors instead of administrators. The government has ring fenced the budget of the NHS, but since there is a built-in inflation in health spending due to demographic drift and scientific development, even a stand-still budget seems like cuts.

So what is wrong with the NHS and what needs fixing?

The last Labour government threw a lot of money at the NHS and brought average spending up to where it was in most of Europe - but of course during the same period Europe also increased its spending so that the NHS still lags behind Germany, Spain and France in its spending. The criticism was made that much of the money was wasted because productivity actually fell while the spending increased. I contend that this was because the government did not believe how hard doctors and nurses were working. The contracts were made more watertight so that people were actually paid for their work and discouraged from doing unpaid overtime by the European Working Time Directive. So it appeared that people were doing less for more. More jobs were created to fill in the gaps.

Another criticism of the NHS was that priorities for treatment had become distorted. Waiting lists had been shortened to no more than 18 weeks anywhere, but this had sometimes meant that things like cosmetic surgery were given priority over mental health services or even cancer surgery. Cancer referrals was supposed to take no more than 2 weeks, but there were built in delays waiting for scans and follow-up appointments. Again every breast lump was placed at the head of the queue even though many of them would be benign cysts.

By giving GPs the budget the idea would be that they could better decide on priorities and not make the same basic errors that administrators would make. On the other hand GPs are themselves providers to the NHS and might find it profitable to favor their own services at the expense of other providers. Near-patient testing or the use of 'factory laboratories' without pathologist's supervision, might be preferred to our conventional model. GPs certainly favored themselves when abandoning night duties to private services for a very small cut in income. The private night services have scored some spectacular own-goals.

One possible drive behind the Conservative reforms has been the possibility of private providers supplying some of the services. I have no problem with this as long as they are professionally scrutinized. We have private catering and waste disposal, and why not. The attempt by Blair's government to introduce private treatment centers for orthopedic operations was disastrous. They cherry-picked the easy options and left their complications to be picked up by the NHS.

The other drawback of private treatment centers is their lack of commitment to training and research which are an essential element of the NHS. One remedy for this would be to ensure that hospital specialists had a say in the purchasing of services, but Lansley is resisting this. Lansley has family members who are family doctors and his might not be an unjaundiced eye.

It seems to me that there some elements of health that have to be provided by the public sector. This is recognized even in America where the CDC and VA are both provided at public expense.

Another question is whether it is possible to restrain the costs of drugs. In any market any product can price itself out of contention. The very rich, like Steve Jobs, will be able to buy anything to keep himself alive; the indigenous poor will not. An insurance system, however provided, evens out the difference, but it will not be attractive to everybody. Attempts to arbitrarily control what is spent will fall foul of individual unfair exceptions. The UK government has set up a cancer fund to deal with these exceptions when NICE seems harsh. It has not been universally acceptable.

I suppose what is wrong with the NHS is what is wrong with modern medicine. It is not universally successful.